Patient Name
Today’s Date
Gender
Preferred Pronoun:
Last Eye Doctor/Location
Date of last eye exam
Primary Care Physician/Location:
Date of last physical exam
Occupation
What is the main reason for your visit today?
Do you have any other visual/ocular problems?
Do you primarily wear glasses?
How old are your current glasses?
Do you wear contact lenses?
Are you interested in a new contact lens design?
Are you interested in refractive surgery (laser or cataract) options?
How many total hours per day do you use a computer, cell phone, tablet or play video games?
Do you use computer glasses?
Are you interested in special glasses to make computer work easier?
What sports/hobbies do you participate in?
Do you wear any special eyewear for your sport/hobby?
Do you currently wear sunglasses?
Are you sensitive to bright lights?
Please check off the following for SEVERITY and FREQUENCY of dry eye symptoms:
Severity of Symptoms
Legend
0 - No problems1 - Tolerable (not perfect, but not uncomfortable)2 - Uncomfortable (irritating, but does not interfere with my day)3 - Bothersome (irritating and interferes with my day)4 - Intolerable (unable to perform my daily tasks)
Dryness, grittiness or scratchiness
Soreness or irritation
Burning or watering
Eye Fatigue
Frequency of Symptoms
Legend0 - Never1 - Sometimes2 - Often3 - Constant
Please check the boxes that apply. Unchecked boxes will mean “no”.
Allergy
Constitutional
Cardiovascular
Endocrine
Gastrointestinal
Genitourinary
Head
Hematologic/ Lymphatic
Immunologic/ Integumentary (Skin)
Musculoskeleta
Neurologic
Psychiatric
Respiratory
Conditions
Surgeries
Ocular
Medical
Name
Dose
Purpose
*Please include over the counter medications, eye drops, vitamins, contraceptives, and herbal supplements.
I verify that the information contained on this page is current.
Patient Signature
Date
All EyeCare Services
KeepIn Touch
At A+ Vision Optometry, we provide the highest quality eye care to all our patients. Schedule your appointment today.
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